The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Maintaining accurate records of intake and output

Maintaining a patent airway

Inserting a nasogastric (NG) tube as prescribed

Providing appropriate pain control

Answer and Explanation

The Correct Answer is B

A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.

B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.

C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.

D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.

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Correct Answer is A

Explanation

A. "My condition is a degenerative brain disorder caused by nutrient deficiency." Wernicke encephalopathy is caused by thiamine (vitamin B1) deficiency, which is often due to chronic alcoholism. The condition is associated with neurological damage from this nutrient deficiency, making this statement accurate.

B. "There is swelling of my brain that is caused by alcohol consumption." Wernicke encephalopathy is not characterized by brain swelling but by neurological damage due to thiamine deficiency.

C. "The inability of my liver to metabolize the alcohol caused this condition." While liver dysfunction can be associated with alcohol use, Wernicke encephalopathy is specifically due to thiamine deficiency, not liver metabolism issues.

D. "Toxins from the alcohol I drank have caused my brain to swell." This statement is incorrect as Wernicke encephalopathy is related to thiamine deficiency rather than brain swelling from alcohol toxins.

A. The client can obtain and maintain employment. B. The client is free from aggressive behaviors. C. The client utilizes relaxation techniques. D. The client maintains healthy relationships with others.

Correct Answer is B

Explanation

A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.

B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.

C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.

D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.

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The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with Wernicke encephalopathy. The nurse determines that teaching has been effective when the client makes which statement?

Correct Answer is A

Explanation

A psychiatric mental-health nurse is evaluating the treatment plan of an adult client diagnosed with schizophrenia disorder with aggressive behaviors. Which outcome of the client would demonstrate successful treatment?

Correct Answer is B

Explanation

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